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Child and adolescent psychiatrists have not been exempt from the monumental changes and pressures brought about by managed care. Three leaders of the American Academy of Child and Adolescent Psychiatrists (AACAP) conveyed their frustrations with managed care to Psychiatric News at the academy’s annual meeting in Toronto last month.
David Pruitt, M.D., AACAP president and director of the division of child and adolescent psychiatry at the University of Tennessee Medical Center in Memphis, described his institution’s challenging experience with the state’s managed Medicaid program. This program, known as TennCare, serves 1.2 million people.
"Since TennCare carved out its mental health services to managed care companies last year, our Medicaid patient base has dropped along with our clinical revenue," said Pruitt. "Because we traditionally have relied on the Medicaid population to meet our clinical and educational mission, we have been struggling to find creative alternatives."
Moreover, TennCare’s management of mental health services has changed twice in the past two years, "creating a lot of confusion and uncertainty for providers, especially within our academic medical center."
TennCare initially contracted with several managed care companies to oversee mental health and physical health services and then carved out its mental health services to two behavioral health companies last year.
Reportedly, TennCare will revert back to the earlier integrated model by the end of the year, said Pruitt.
"The capitation model we had in the beginning with TennCare allowed us to control patient costs and quality of care," he said. "But since the mental health services were carved out, we have been forced to enter deeply discounted fee-for-service arrangements. We have had less control in providing treatment that we feel is important and necessary, and staff morale has declined."
Moreover, the state maintains that the mental health carveout is losing money and adversely affecting patient care.
Psychiatrists in private psychiatric hospitals also are feeling the demoralizing effect of managed care, said Lawrence Stone, M.D., who completed his term as AACAP’s president at the close of the academy’s annual meeting.
"We feel that our ability to make treatment and length-of-stay decisions has been eroded because of financial considerations," said Stone, executive medical director of the Laurel Ridge Hospital in San Antonio, Tex., a private psychiatric hospital for severely mentally ill children. "This hinders our therapeutic alliance with patients and their families."
Stone mentioned that the number of beds in his hospital substantially decreased in the last decade from an average of 170 to an average of 100. The length of stay for acute services has gone from an average of three weeks to five to seven days.
"The need for psychiatric inpatient care has not changed, but the demand has, because more families are not being referred to specialists by their primary care providers," said Stone. "As a result, we are seeing more frequent rehospitalizations."
Because managed care companies limit the psychiatrist’s treatment and time, children get less individual therapy and are seen by mental health professionals with less training.
Lost income from managed care in the last three years forced the hospital to reduce the number of staff psychiatrists.
Child psychiatrists are enough in demand that managed care companies must deal with them, said William Ayres, M.D., a former AACAP president and a private practitioner with Peninsula Psychiatric Associates, a multidisciplinary group practice in San Mateo, Calif.
Although managed care referrals mean more patients, child psychiatrists in large urban areas are seeing a drop in income because of discounted reimbursement fees, Ayres added.
He complained that some managed care companies are excluding certain services from reimbursement, such as a two-hour family evaluation session or two visits so that a child and his or her parents can be seen separately.
"The managed care view is [that] you can do an adequate family evaluation in 10 or 20 minutes," said Ayres. "Child and adolescent psychiatrists may choose instead to have the child leave during part of the meeting and bill a family session to one individual."
Treatment for psychiatric diagnoses such as ADHD or conduct disorder is not being covered by certain managed care plans, said Ayres.
He noted, however, that "AACAP has been successful in reversing such categorical exclusions with Blue Cross in Maryland and Vermont, for example.
"In California, which has more than 100 different health plans, we are more likely to appeal managed care denials because the professional risk is minimal compared with psychiatrists in Boston, for example, who deal with only three major plans."
Ayres, who has been in practice more than 35 years, has developed a large referral base. He has become so dissatisfied with managed care business practices that he refuses to deal with them, he said.
"Even a younger psychiatrist who joined our practice recently has a busy patient load and is excluding managed care. In the San Mateo area, which is between San Francisco and Palo Alto, there are enough patients willing to pay out of pocket that child psychiatrists are doing fine without managed care."